CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 28 21.75 804.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 34 57.00 2109.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 136.50 5050.50 37.00
Subtotal (Total Children Is Unduplicated) 47 215.25 7964.25 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.00 100.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 12.00 825.00 68.75
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 75.00 50.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 75.00 50.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 12.50 825.00 66.00
Subtotal (Total Children Is Unduplicated) 14 29.50 1900.00 64.41
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 26 1620.00 830.00 0.51
Subtotal (Total Children Is Unduplicated) 26 1620.00 830.00 0.51
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Total 1864.75 10694.25 5.73
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Number of Children (Unduplicated) With at Least One Service 48
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Center 51
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 66 1645.50 2505.00 2505.00
D 1 0.50 18.50 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
293 218.75 8170.75 0.00
Other 0 0.00 0.00 0.00
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Total 360 1864.75 10694.25 2505.00